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shipTRANSCRIPT
MANNING AGENCY AGREEMENT dated [ ]
CRW13 APPLICATION FOR EMPLOYMENT
x
Personal DataAFFIX HERE YOUR RECENT PASSPORT SIZE PHOTOGRAPH
First Name KHALID
Middle NameLast Name / Surname MEHBOOB
Nationality PAKISTANIDate Of Birth (dd/mm/yy) 10-04-1960Place of Birth KARACHI-PAKISTAN
Position Applied For CHIEF ENGINEER Female x MaleAvailable date -DEC,2014
Home Address-112-Q PECHS BLOCK-2,KARACHI.
Personal DocumentsIssued onValid until
Passport (Country / Number)
PAKISTAN/AB955004319-SEP 201417-SEP 2024
Seamans book
010857-EO06-MARCH 201005-MACH 2020
USA C1/D visa
Telephone
021-34553212,0334-3971277Schengen Visa
[email protected] Fitness Certificate
National Certificates of Competence country_____PAKISTAN__________________Tanker Endorsements
Management level x Operation level
GradeIssuedExpiresOilChemicalGas
CLASS-123 RD OCT,200320-11-20171032l
Valid Flag State Endorsements Liberia FORMCHECKBOX , Panama FORMCHECKBOX , Malta x FORMCHECKBOX , Marshall Islands FORMCHECKBOX , UK , Singapore FORMCHECKBOX Norway (DIS) FORMCHECKBOX ,
Other (list flags) FORMCHECKBOX Isle of Man &.Republic of Cyprus
GMDSSGeneral /RestrictedFlag State GMDSS Endorsements (list)
Other valid certificates and training attended
x FORMCHECKBOX Basic Safety Training x FORMCHECKBOX Advanced Fighting x FORMCHECKBOX Medical First Aid FORMCHECKBOX Medical Care FORMCHECKBOX ECDIS (generic)
http://www.wcck.net/forums/showthread.php?t=797&page=9 FORMCHECKBOX ECDIS (type specific) FORMCHECKBOX Bridge Team Management FORMCHECKBOX Ship Handling FORMCHECKBOX Liquid Cargo Handling FORMCHECKBOX ER Management FORMCHECKBOX Other (specify)
Please answer the following questions:
Did you suffer, or presently suffer from any disease likely to render you unfit for services at sea or likely to endanger the health of other persons on board?
If yes, please provide details ________________________________________________________ _______________________________________________________________________________ FORMCHECKBOX YES FORMCHECKBOX NO
Did you suffer any accident, which rendered you temporary and/or partially disabled? FORMCHECKBOX YES FORMCHECKBOX NO
Did you ever undergo psychiatric treatment FORMCHECKBOX YES FORMCHECKBOX NO
Are you addicted to alcohol or drugs of any kind? FORMCHECKBOX YES FORMCHECKBOX NO
I hereby declare that the above facts and information are true and accurate. I further consent to the holding and processing by (i) the owners of any vessel on which I may be assigned from time to time and (ii) the Managers and any direct or indirect parent or subsidiary or associated or affiliated company of the Managers (together referred to as "the Companies") for the purposes of my employment, of personal data about me contained herein, or provided to any of the Companies at a later date, including with respect to personal and pensions administration, employee management and as required to comply with any laws, regulations or contracts applicable to any of the Companies or their businesses. I understand that this data will be stored in the Managers database for the purposes of my current or future employment arranged by the Managers. Further, I confirm that the above may involve the transfer of my personal data within the Managers organization.Place_____KARACHI____________ Date ______29.08.14________ Signature ____KHALID____________________For Office UseInitial assessment of applicant for further recruitment
Comments ___________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
MSO responsible person
Name / Signature _______________________________________________ Date ________________________________Sea Experience : (Last 5 years; Start the listing below with the most recent experience)CompanyFlagVessel NameType (1)GRTDWTMain Engine (2)BHPChief EngineerDate From
(dd/mm/yy)Date To
(dd/mm/yy)Reason for S/off (3)
Blnheim Shipping UK ltdIOMStar LadyTNC56204105000Sulzer-6RT-Flex16320Chief Engineer14/03/1411/08/14EOC
Blenheim shipping UKIOMMoon LadyTNC55894105000Mitsui.MAN B&W16791Chief Engineer26/09/1318/02/14EOC
N.I.T.CLIMASSOLFreedomTNV163660317138MAN,B&W6S90Mc-C39330Chief Engineer23.01.1301.05.13EOC
N.I.T.CLIMASSOLFreedomTNV163660317138MAN,B&W6S90Mc-C39330Chief Engineer22.12.1116-09.12EOC
N.I.T.CLIMASSOLM.T.HarazTNV163660317138MAN,B&W6S90Mc-C39330Chief Engineer27.02.1123.06.11EOC
N.I.T.CIRANM.T.DelvarTNV160857296,803Sulzer7RTA 84-B36960Chief Engineer27.04.1026.12.10EOC
N.I.T.CIRANM.T.DelvarTNV160857296,803Sulzer7RTA 84-B36960Chief Engineer29.04.0919.11.09EOC
N.I.T.CVALLETTAM.T.ASTARATNC5600099,148Sulzer7RTA 58T-B20,230Chief Engineer03.05.0817.11.08EOC
N.I.T.CFreedomTNC
VALLETTAM.T.ASTENEHTNC5600099,148Sulzer7RTA 58T-B20,230Chief Engineer27.08.0730.12.07EOC
N.I.T.CVALLETTAM.T.ABDANTNC5600099,148Sulzer7RTA 58T-B20,230Chief Engineer06.05.0711.07.07EOC
N.I.T.CVALLETTAM.T.ASTENEHTNC5600099,148Sulzer7RTA 58T-B20,230Chief Engineer30.10.0616.04.07EOC
N.I.T.CVALLETTAM.T.ABDANTNC5600099,148Sulzer7RTA 58T-B20,230Chief Engineer08.03.0603.09.06EOC
Chief Engineer
*Please use only following abbreviations for the vessel type: GCD General CargoMLP Multi-PurposeB/C Bulk CarrierCON Container O/O Ore OilOBO Ore/Bulk/Oil
TNC Tanker CrudeTNP Tanker ProductFSO / FPSO TNV VLCC/ULCC LPG
CHM Chemical TankPAS Passenger ShipR/O Ro/RoLSH LashDRG DredgerOSV Offshore Supply LNGSRV Survey vesselLOG Log/TimberNVL Naval ShipSSHL Semi-Submergible Heavy LiftMOB Mobile Offshore Unit
(1) Use only the following abbreviations for vsl types:
(2) Engineers to give make/model of engines, e.g. MAN 14V52/55A or SULZER 5RTA58
(3) Reason of Sing Off, e.g. EOC End of Contract, MED Medical Ground, OWN Own requestPlease provide details of two recent employers who we may contact for references
Name of Company
Name of person to contact
Address
Telephone/E-Mail
Page 1 of 3 CRW13 Application Form Revision Number: 4.1 File Ref: Office File: 11B